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Cardiogenic Shock: Collaboration Between Cardiac Surgery and Cardiology Subspecialties to Bridge to Recovery

2007; Elsevier BV; Volume: 83; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2006.11.067

1552-6259

Louis E. Samuels, Elena C. Holmes, Kevin Hagan, Robert Boova, Sean Janzer, Dusan Z. Kocovic,

Cardiac Arrest and Resuscitation

Acute cardiogenic shock is a lethal condition that results in death from myocardial failure, arrhythmia, or combinations of both. Aggressive medical, surgical, and interventional maneuvers have helped reduce the mortality. For the most advanced cases, ventricular assist devices have been used for persistent shock states. The purpose of this report is to describe the collaboration between cardiac surgery and cardiology subspecialty in an effort to promote native heart recovery in a complex case of cardiogenic shock requiring coronary artery bypass surgery, percutaneous coronary intervention, ventricular ablative therapy, and mechanical cardiac support. Acute cardiogenic shock is a lethal condition that results in death from myocardial failure, arrhythmia, or combinations of both. Aggressive medical, surgical, and interventional maneuvers have helped reduce the mortality. For the most advanced cases, ventricular assist devices have been used for persistent shock states. The purpose of this report is to describe the collaboration between cardiac surgery and cardiology subspecialty in an effort to promote native heart recovery in a complex case of cardiogenic shock requiring coronary artery bypass surgery, percutaneous coronary intervention, ventricular ablative therapy, and mechanical cardiac support. Dr Samuels discloses that he has a financial relationship with Abiomed Inc.The AB5000 Ventricular Assist Device (VAD) (Abiomed Inc, Danvers, MA) is a paracorporeal system introduced as an upgrade to the BVS5000 unit (Abiomed) [1Samuels L.E. Holmes E.C. Garwood P. et al.Initial experience with the Abiomed AB5000 ventricular assist device.Ann Thorac Surg. 2005; 80: 309-312Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. The Food and Drug Administration approved indication for use of the AB5000 VAD in any type of acute cardiogenic shock that is potentially reversible. Among the most common reasons for its use has been cardiogenic shock after acute myocardial infarction or after coronary artery bypass grafting. The goal is myocardial recovery with eventual VAD explantation. However, among the reasons for recovery failure is persistent myocardial dysfunction or intractable arrhythmia associated with VAD dependence, or both. The purpose of this report is to describe the role of percutaneous coronary intervention and arrhythmia ablative therapy as adjuncts to VAD support resulting in successful myocardial recovery.A 66-year-old man presented to the emergency department with progressive shortness of breath. A pulmonary evaluation showed diffuse pulmonary infiltrates on chest roentgenogram and a positive influenza A titer on serology. After admission, the patient had substernal chest pain develop and was found to have suffered a myocardial infarction. Cardiac catheterization showed severe coronary artery disease with left main involvement. Several days later he underwent coronary artery bypass grafting. The initial postoperative period was unremarkable with no perioperative arrhythmia. After transfer to the step down unit, the patient suffered an acute ventricular tachycardia with fibrillation arrest requiring cardiopulmonary resuscitation and multiple defibrillations. Hemodynamic instability persisted with intractable ventricular arrhythmia requiring his return to the operating room, establishment of cardiopulmonary bypass, and preparation for VAD placement. An Abiomed BVS5000 LVAD was placed with inflow from the left atrium and outflow to the ascending aorta.The patient was transferred to Lankenau Hospital for further management. Coronary angiography was performed showing patent bypass grafts and the same subtotal ostial left main stenosis observed in the initial study. Because there was concern about the possibility of residual ischemia from a large (unbypassed) ramus intermedius branch, a 3.0 × 12 mm Liberte bare metal stent (Boston Scientific Inc, Natick, MA) was placed in the left main. The next day, the BVS5000 was switched to the AB5000 ventricle because of thrombus formation in the BVS5000 blood pump. While on VAD support, his ventricular dysrhythmias continued despite amiodarone and lidocaine infusions. Electrophysiology consultation was obtained. Based on multiple rhythm strips, the impression was that the episodes of polymorphic ventricular tachycardia were initiated exactly the same way by a single ventricular premature depolarization, most likely related to the Purkinje system at the interventricular septum. Because lidocaine would have no effect on this condition and amiodarone was ineffective in suppressing the ventricular tachycardia, the patient's treatment was changed to procainamide and was considered a candidate for radiofrequency ablation. The patient was taken to the electrophysiology laboratory where mapping and ablation took place. The procedure consisted of pacing in the right ventricle at 300 msec, which induced the left-sided ventricular premature depolarization resulting in a reproducible ventricular tachycardia. Using a Chilli catheter (Boston Scientific Inc, Natick, MA), four radiofrequency lesions were placed in the left ventricular aspect of the posteromedial mitral valve annulus. Attempts at reinducing the ventricular tachycardia from the right ventricle and the left ventricle failed to cause the ventricular tachycardia previously observed. Post-procedure, the patient was maintained on procainamide with no further episodes of arrhythmia in normal sinus rhythm. After a week of a stable cardiac rhythm, the VAD was explanted, approximately 3 weeks since the original implant.The patient remained in the hospital for several weeks, requiring a percutaneous tracheostomy and gastrostomy. Approximately 3 weeks after removing the VAD, the patient was transferred to a rehabilitation center having been successfully weaned from the ventilator and eating orally. Prior to his discharge, a dual-chamber Entrust Implantable Cardiac Defibrillator (Medtronic Inc, Minneapolis, MN) was implanted. For the next several months the procainamide was discontinued and metoprolol was up titrated to maintain a heart rate between 50 and 60 bpm. At 6-months follow-up the patient remains alive and well in New York Heart Association functional class II.CommentAcute myocardial infarction with cardiogenic shock is associated with a high mortality [2Hochman J.S. Sleeper L.A. Webb J.G. et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2193) Google Scholar]. Despite therapies with lytic agents and an intraaortic balloon pump, the in-hospital mortality rate is 47% [3Sanborn T.A. Sleeper L.A. Bates E.R. et al.Impact of thrombolytic, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry.Should we emergently revascularize Occluded Coronaries for cardiogenic shock? J Am Coll Cardiol. 2000; 36: 1123-1129Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar]. The most common causes of death include pump failure or arrhythmia, or both. Post-cardiotomy shock has an equally high mortality with death rates reaching 80% in the setting of low cardiac output and need for multiple high-dose inotropic drugs [4Samuels L.E. Kaufman M.S. Thomas M.P. et al.Pharmacological criteria for ventricular assist device insertion following postcardiotomy shock: experience with the Abiomed BVS 5000 system.J Card Surg. 1999; 14: 288-293Crossref PubMed Scopus (117) Google Scholar]. The use of VAD technology for cardiogenic shock has received a considerable amount of attention with varying degrees of survival based on timing of insertion, age, comorbidities, duration of support, and experience of the implanting center and surgeon [5Samuels L.E. Darze D.S. Management of acute cardiogenic shock.Cardiol Clinics. 2003; 21: 43-49Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. However, survivors fall into two categories: (1) those who were bridged to native heart recovery and (2) those who were bridged to transplantation. It has been our experience that patients successfully bridged to recovery were those that had ancillary procedures done at the time of VAD insertion or shortly thereafter. As shown in the shock trial, the addition of revascularization to supportive therapy had a favorable impact on both short-term and intermediate-term survival [2Hochman J.S. Sleeper L.A. Webb J.G. et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2193) Google Scholar]. Despite the experience of others, in which the use of VADs for acute myocardial infarction shock is more toward its use as a bridge-to-transplantation [6Leshnower B.G. Gleason T.G. O'Hara M.L. et al.Safety and efficacy of left ventricular assist device support in postmyocardial infarction cardiogenic shock.Ann Thorac Surg. 2006; 81: 1365-1370Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 7Dang N.C. Topkara V.K. Leacche M. et al.Left ventricular assist device implantation after acute anterior wall myocardial infarction and cardiogenic shock: a two-center study.J Thorac Cardiovasc Surg. 2005; 130: 693-698Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar], we generally approach the acute cardiogenic shock patient with the possibility of recovering the native heart function as a primary goal. As such, our programmatic approach is to enhance recovery with maximal left ventricular unloading and end-organ support with the VAD as well as perform revascularization with percutaneous coronary intervention or coronary artery bypass grafting and ablative therapy for refractory ventricular arrhythmias (Fig 1), or a combination thereof. As was the case presented here, the approach to myocardial recovery in these instances requires the collaborative efforts between cardiac surgery and cardiology. Although several reports describe the role of VADs for elective high-risk percutaneous coronary intervention [8Kar B. Forrester M. Gemmato C. et al.Use of the TandemHeart percutaneous ventricular assist device to support patients undergoing high-risk percutaneous coronary intervention.J Invasive Cardiol. 2006; 18: 97-98PubMed Google Scholar, 9Ramondo A. Napodano M. Tarantini G. et al.High-risk percutaneous coronary intervention using the intracardiac microaxial pump "Impella recover.".J Cardiovasc Med. 2006; 7: 149-152Crossref Scopus (8) Google Scholar], the type of VAD, which is usually a micro-axial flow pump (eg, TandemHeart [CardiacAssist, Pittsburgh, PA] or Impella [Abiomed Inc, Danvers, MA]), is different from the one used in this case, and the addition of ablative therapy we believe has not been previously described.In conclusion, collaboration between cardiac surgery and cardiology, in the form of mechanical support and percutaneous interventions (ie, coronary angioplasty and ablative therapy) can be accomplished with the goal of restoring and maintaining native heart recovery. We favor an aggressive approach to promote myocardial recovery, and we utilize the surgical and medical resources to accomplish this end. In the absence of recovery, transplantation of permanent VAD therapy is appropriate. Dr Samuels discloses that he has a financial relationship with Abiomed Inc. Dr Samuels discloses that he has a financial relationship with Abiomed Inc. Dr Samuels discloses that he has a financial relationship with Abiomed Inc. The AB5000 Ventricular Assist Device (VAD) (Abiomed Inc, Danvers, MA) is a paracorporeal system introduced as an upgrade to the BVS5000 unit (Abiomed) [1Samuels L.E. Holmes E.C. Garwood P. et al.Initial experience with the Abiomed AB5000 ventricular assist device.Ann Thorac Surg. 2005; 80: 309-312Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. The Food and Drug Administration approved indication for use of the AB5000 VAD in any type of acute cardiogenic shock that is potentially reversible. Among the most common reasons for its use has been cardiogenic shock after acute myocardial infarction or after coronary artery bypass grafting. The goal is myocardial recovery with eventual VAD explantation. However, among the reasons for recovery failure is persistent myocardial dysfunction or intractable arrhythmia associated with VAD dependence, or both. The purpose of this report is to describe the role of percutaneous coronary intervention and arrhythmia ablative therapy as adjuncts to VAD support resulting in successful myocardial recovery. A 66-year-old man presented to the emergency department with progressive shortness of breath. A pulmonary evaluation showed diffuse pulmonary infiltrates on chest roentgenogram and a positive influenza A titer on serology. After admission, the patient had substernal chest pain develop and was found to have suffered a myocardial infarction. Cardiac catheterization showed severe coronary artery disease with left main involvement. Several days later he underwent coronary artery bypass grafting. The initial postoperative period was unremarkable with no perioperative arrhythmia. After transfer to the step down unit, the patient suffered an acute ventricular tachycardia with fibrillation arrest requiring cardiopulmonary resuscitation and multiple defibrillations. Hemodynamic instability persisted with intractable ventricular arrhythmia requiring his return to the operating room, establishment of cardiopulmonary bypass, and preparation for VAD placement. An Abiomed BVS5000 LVAD was placed with inflow from the left atrium and outflow to the ascending aorta. The patient was transferred to Lankenau Hospital for further management. Coronary angiography was performed showing patent bypass grafts and the same subtotal ostial left main stenosis observed in the initial study. Because there was concern about the possibility of residual ischemia from a large (unbypassed) ramus intermedius branch, a 3.0 × 12 mm Liberte bare metal stent (Boston Scientific Inc, Natick, MA) was placed in the left main. The next day, the BVS5000 was switched to the AB5000 ventricle because of thrombus formation in the BVS5000 blood pump. While on VAD support, his ventricular dysrhythmias continued despite amiodarone and lidocaine infusions. Electrophysiology consultation was obtained. Based on multiple rhythm strips, the impression was that the episodes of polymorphic ventricular tachycardia were initiated exactly the same way by a single ventricular premature depolarization, most likely related to the Purkinje system at the interventricular septum. Because lidocaine would have no effect on this condition and amiodarone was ineffective in suppressing the ventricular tachycardia, the patient's treatment was changed to procainamide and was considered a candidate for radiofrequency ablation. The patient was taken to the electrophysiology laboratory where mapping and ablation took place. The procedure consisted of pacing in the right ventricle at 300 msec, which induced the left-sided ventricular premature depolarization resulting in a reproducible ventricular tachycardia. Using a Chilli catheter (Boston Scientific Inc, Natick, MA), four radiofrequency lesions were placed in the left ventricular aspect of the posteromedial mitral valve annulus. Attempts at reinducing the ventricular tachycardia from the right ventricle and the left ventricle failed to cause the ventricular tachycardia previously observed. Post-procedure, the patient was maintained on procainamide with no further episodes of arrhythmia in normal sinus rhythm. After a week of a stable cardiac rhythm, the VAD was explanted, approximately 3 weeks since the original implant. The patient remained in the hospital for several weeks, requiring a percutaneous tracheostomy and gastrostomy. Approximately 3 weeks after removing the VAD, the patient was transferred to a rehabilitation center having been successfully weaned from the ventilator and eating orally. Prior to his discharge, a dual-chamber Entrust Implantable Cardiac Defibrillator (Medtronic Inc, Minneapolis, MN) was implanted. For the next several months the procainamide was discontinued and metoprolol was up titrated to maintain a heart rate between 50 and 60 bpm. At 6-months follow-up the patient remains alive and well in New York Heart Association functional class II. CommentAcute myocardial infarction with cardiogenic shock is associated with a high mortality [2Hochman J.S. Sleeper L.A. Webb J.G. et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2193) Google Scholar]. Despite therapies with lytic agents and an intraaortic balloon pump, the in-hospital mortality rate is 47% [3Sanborn T.A. Sleeper L.A. Bates E.R. et al.Impact of thrombolytic, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry.Should we emergently revascularize Occluded Coronaries for cardiogenic shock? J Am Coll Cardiol. 2000; 36: 1123-1129Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar]. The most common causes of death include pump failure or arrhythmia, or both. Post-cardiotomy shock has an equally high mortality with death rates reaching 80% in the setting of low cardiac output and need for multiple high-dose inotropic drugs [4Samuels L.E. Kaufman M.S. Thomas M.P. et al.Pharmacological criteria for ventricular assist device insertion following postcardiotomy shock: experience with the Abiomed BVS 5000 system.J Card Surg. 1999; 14: 288-293Crossref PubMed Scopus (117) Google Scholar]. The use of VAD technology for cardiogenic shock has received a considerable amount of attention with varying degrees of survival based on timing of insertion, age, comorbidities, duration of support, and experience of the implanting center and surgeon [5Samuels L.E. Darze D.S. Management of acute cardiogenic shock.Cardiol Clinics. 2003; 21: 43-49Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. However, survivors fall into two categories: (1) those who were bridged to native heart recovery and (2) those who were bridged to transplantation. It has been our experience that patients successfully bridged to recovery were those that had ancillary procedures done at the time of VAD insertion or shortly thereafter. As shown in the shock trial, the addition of revascularization to supportive therapy had a favorable impact on both short-term and intermediate-term survival [2Hochman J.S. Sleeper L.A. Webb J.G. et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2193) Google Scholar]. Despite the experience of others, in which the use of VADs for acute myocardial infarction shock is more toward its use as a bridge-to-transplantation [6Leshnower B.G. Gleason T.G. O'Hara M.L. et al.Safety and efficacy of left ventricular assist device support in postmyocardial infarction cardiogenic shock.Ann Thorac Surg. 2006; 81: 1365-1370Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 7Dang N.C. Topkara V.K. Leacche M. et al.Left ventricular assist device implantation after acute anterior wall myocardial infarction and cardiogenic shock: a two-center study.J Thorac Cardiovasc Surg. 2005; 130: 693-698Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar], we generally approach the acute cardiogenic shock patient with the possibility of recovering the native heart function as a primary goal. As such, our programmatic approach is to enhance recovery with maximal left ventricular unloading and end-organ support with the VAD as well as perform revascularization with percutaneous coronary intervention or coronary artery bypass grafting and ablative therapy for refractory ventricular arrhythmias (Fig 1), or a combination thereof. As was the case presented here, the approach to myocardial recovery in these instances requires the collaborative efforts between cardiac surgery and cardiology. Although several reports describe the role of VADs for elective high-risk percutaneous coronary intervention [8Kar B. Forrester M. Gemmato C. et al.Use of the TandemHeart percutaneous ventricular assist device to support patients undergoing high-risk percutaneous coronary intervention.J Invasive Cardiol. 2006; 18: 97-98PubMed Google Scholar, 9Ramondo A. Napodano M. Tarantini G. et al.High-risk percutaneous coronary intervention using the intracardiac microaxial pump "Impella recover.".J Cardiovasc Med. 2006; 7: 149-152Crossref Scopus (8) Google Scholar], the type of VAD, which is usually a micro-axial flow pump (eg, TandemHeart [CardiacAssist, Pittsburgh, PA] or Impella [Abiomed Inc, Danvers, MA]), is different from the one used in this case, and the addition of ablative therapy we believe has not been previously described.In conclusion, collaboration between cardiac surgery and cardiology, in the form of mechanical support and percutaneous interventions (ie, coronary angioplasty and ablative therapy) can be accomplished with the goal of restoring and maintaining native heart recovery. We favor an aggressive approach to promote myocardial recovery, and we utilize the surgical and medical resources to accomplish this end. In the absence of recovery, transplantation of permanent VAD therapy is appropriate. Acute myocardial infarction with cardiogenic shock is associated with a high mortality [2Hochman J.S. Sleeper L.A. Webb J.G. et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2193) Google Scholar]. Despite therapies with lytic agents and an intraaortic balloon pump, the in-hospital mortality rate is 47% [3Sanborn T.A. Sleeper L.A. Bates E.R. et al.Impact of thrombolytic, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry.Should we emergently revascularize Occluded Coronaries for cardiogenic shock? J Am Coll Cardiol. 2000; 36: 1123-1129Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar]. The most common causes of death include pump failure or arrhythmia, or both. Post-cardiotomy shock has an equally high mortality with death rates reaching 80% in the setting of low cardiac output and need for multiple high-dose inotropic drugs [4Samuels L.E. Kaufman M.S. Thomas M.P. et al.Pharmacological criteria for ventricular assist device insertion following postcardiotomy shock: experience with the Abiomed BVS 5000 system.J Card Surg. 1999; 14: 288-293Crossref PubMed Scopus (117) Google Scholar]. The use of VAD technology for cardiogenic shock has received a considerable amount of attention with varying degrees of survival based on timing of insertion, age, comorbidities, duration of support, and experience of the implanting center and surgeon [5Samuels L.E. Darze D.S. Management of acute cardiogenic shock.Cardiol Clinics. 2003; 21: 43-49Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. However, survivors fall into two categories: (1) those who were bridged to native heart recovery and (2) those who were bridged to transplantation. It has been our experience that patients successfully bridged to recovery were those that had ancillary procedures done at the time of VAD insertion or shortly thereafter. As shown in the shock trial, the addition of revascularization to supportive therapy had a favorable impact on both short-term and intermediate-term survival [2Hochman J.S. Sleeper L.A. Webb J.G. et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2193) Google Scholar]. Despite the experience of others, in which the use of VADs for acute myocardial infarction shock is more toward its use as a bridge-to-transplantation [6Leshnower B.G. Gleason T.G. O'Hara M.L. et al.Safety and efficacy of left ventricular assist device support in postmyocardial infarction cardiogenic shock.Ann Thorac Surg. 2006; 81: 1365-1370Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 7Dang N.C. Topkara V.K. Leacche M. et al.Left ventricular assist device implantation after acute anterior wall myocardial infarction and cardiogenic shock: a two-center study.J Thorac Cardiovasc Surg. 2005; 130: 693-698Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar], we generally approach the acute cardiogenic shock patient with the possibility of recovering the native heart function as a primary goal. As such, our programmatic approach is to enhance recovery with maximal left ventricular unloading and end-organ support with the VAD as well as perform revascularization with percutaneous coronary intervention or coronary artery bypass grafting and ablative therapy for refractory ventricular arrhythmias (Fig 1), or a combination thereof. As was the case presented here, the approach to myocardial recovery in these instances requires the collaborative efforts between cardiac surgery and cardiology. Although several reports describe the role of VADs for elective high-risk percutaneous coronary intervention [8Kar B. Forrester M. Gemmato C. et al.Use of the TandemHeart percutaneous ventricular assist device to support patients undergoing high-risk percutaneous coronary intervention.J Invasive Cardiol. 2006; 18: 97-98PubMed Google Scholar, 9Ramondo A. Napodano M. Tarantini G. et al.High-risk percutaneous coronary intervention using the intracardiac microaxial pump "Impella recover.".J Cardiovasc Med. 2006; 7: 149-152Crossref Scopus (8) Google Scholar], the type of VAD, which is usually a micro-axial flow pump (eg, TandemHeart [CardiacAssist, Pittsburgh, PA] or Impella [Abiomed Inc, Danvers, MA]), is different from the one used in this case, and the addition of ablative therapy we believe has not been previously described. In conclusion, collaboration between cardiac surgery and cardiology, in the form of mechanical support and percutaneous interventions (ie, coronary angioplasty and ablative therapy) can be accomplished with the goal of restoring and maintaining native heart recovery. We favor an aggressive approach to promote myocardial recovery, and we utilize the surgical and medical resources to accomplish this end. In the absence of recovery, transplantation of permanent VAD therapy is appropriate.